Comprehensive, up-to-date information on HIV/AIDS treatment, prevention, and policy from the University of California San Francisco

Systematic Review of HIV Behavioral Prevention Research in Asian Americans and Pacific Islanders

HIV InSite Knowledge Base ChapterApril 2002

Lynae A. Darbes, PhD, University of California San FranciscoGail E. Kennedy, MPH, University of California San FranciscoGreet Peersman, PhD, Centers for Disease Control and PreventionLev Zohrabyan, MD, MPH, Emory UniversityGeorge W. Rutherford, MD, University of California San Francisco

This systematic review was commissioned by the Surgeon General's Leadership Campaign on AIDS and was completed in collaboration by the University of California, San Francisco AIDS Research Institute and the Cochrane Collaborative Review Group on HIV/AIDS. Supported by a grant from the Leadership Conference on AIDS and the Office of Minority Health, Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services.

We conducted a systematic review of the HIV prevention intervention literature for Asian Americans and Pacific Islanders (API) in the United States. We focused on the four major risk groups (men who have sex with men (MSM), injection drug users (IDU), heterosexuals, and youth/adolescents). We utilized the techniques of evidence-based medicine to identify the best evidence for effective HIV prevention interventions. We developed a standard set of inclusion and exclusion criteria based on the methodological quality of the study and our ability to extract information specific to API participants. Following a rigorous search of the literature and an application of our inclusion criteria, we identified 2 methodologically sound controlled intervention trials.

We found that certain components produced positive results. Cultural sensitivity and skills training were present in the successful intervention. Examples of positive outcomes included decreasing the number of sexual partners, decreasing the frequency of unprotected anal intercourse, and increasing knowledge about HIV. These outcomes are associated with decreasing HIV infection. Only 1 of the 2 studies was of high methodological quality. The most significant research gaps identified were the paucity of literature conducted within the Asian American and Pacific Islander community in general and, specifically, the lack of interventions targeted toward API men who have sex with men (MSM). We identified only one published intervention for this group. In addition, we did not identify any published interventions for API adolescents, and only one study among API heterosexuals.

In sum, we found some evidence that interventions aimed toward decreasing HIV risk infections in API can be successful, though more research is urgently needed. Future interventions should incorporate those components that have been demonstrated to be effective in order to better prevent further harm to the API community from the HIV epidemic.

Background

Evidence-based medicine is "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." This model of medical practice has been extended to public health practice, such as the Centers for Disease Control and Prevention's (CDC) recent community preventive services guidelines project. Central to this practice is the identification of the best evidence to answer specific clinical questions, and the critical appraisal of that evidence. One such approach is to conduct a systematic review. Systematic reviews cull from the methods of meta-analysis and combine a comprehensive and detailed search for relevant studies, a critical appraisal of the quality of included studies, a qualitative synthesis of study findings and, if appropriate, a meta-analysis of the data to determine the combined effect size of similar interventions. Using these methods, we have prepared the present report to identify the best evidence for effective HIV prevention interventions that are of use in Asian American and Pacific Islander (API) populations throughout the United States.

HIV Infection and AIDS among Asian Americans and Pacific Islanders

Although we are entering the third decade of the HIV pandemic, there is as yet no cure or vaccine. At this time, our principal means for deterring the further spread of HIV remains behavioral prevention interventions. Thus, developing and implementing interventions that focus on behavioral prevention are of utmost importance.

API represent the fastest growing ethnic community in the U.S..(1) At approximately 10 million people, currently API comprise 13% of the non-white U.S. population. As of 1990, 66% of Asians and 87% of Pacific Islanders were foreign-born.(2) Chinese, Filipinos, and Japanese represent the largest sub-groups of Asians while Hawaiians, Samoans, and Guamanians are the largest sub-groups of Pacific Islanders in the U.S. Three states (California, New York, and Hawaii) contain 57% of the API population in the U.S..(3)

In addition, API are a diverse group, comprised of multi-generational Americans and immigrants from countries such as Vietnam, the Philippines, India, and China. The cultural differences among API make prevention efforts more complicated, as efforts may need to be targeted for different ethnicities. Furthermore, even though the API population has a higher education level than the U.S. population as a whole and a similar median income, the poverty rate for API families is double that of white families,(4) which may place some at increased risk for HIV. Potential language barriers also exist, which may also hinder prevention efforts. These factors underscore the necessity for examining evidence for prevention interventions aimed at API, focusing on the primary risk groups.

API have consistently represented approximately 1% of AIDS cases.(5) Most of the cases (63%) have been among men who have sex with men (MSM).(5) For API women heterosexual contact is the primary mode of transmission, which differs from African-American women and Latinas (whose primary mode of transmission is via injection drug use).(5)

However, differences in risk are also present within the API population itself. The best data regarding differences in sub-groups of API comes from the states with the highest numbers of API. In California for the years 1980-1995, Filipinos had the highest number of cumulative AIDS cases (34%). Hawaiians (living in California) comprised 4% of the cumulative API AIDS cases but had the highest cumulative AIDS incidence (206.1 per 100,000).(6) API born in the U.S. comprise the second largest group (19%), followed by Chinese (12%), Filipinos (11%), Asian Indians (9%), and Japanese (6%).(7) In Hawaii, native Hawaiians account for 39% of the AIDS cases among API and 12% of cumulative AIDS cases (second to whites).

Globally, 20% of current HIV infections stem from Asia.(8) In examining AIDS figures for Asia, the epidemic has reached the most severe stages in India, Thailand, Cambodia, and, more recently, China. In India the primary modes of transmission are heterosexual sex and injection drug use.(9) UNAIDS estimates the current number of HIV infections in India to be 3.7 million. In Thailand, AIDS was recently named as the leading cause of death.(10) Chinese officials reported that the infection rate for the first half of 2001 had increased by 67%. In China the primary mode of transmission appears to be injection drug use.(11)

Gay Men and Men Who Have Sex with Men

MSM represent the largest risk category for HIV infection in the United States.(5) MSM comprise 74% of the cases of AIDS among API since the beginning of the epidemic and 52% of the new AIDS cases.

Engaging in anal intercourse increases the risk of HIV transmission when condoms are not used. During the late 1980s and early 1990s, dramatic increases in condom use for anal intercourse among MSM were observed.(12) For example, statistics from the San Francisco Men's Health Study demonstrated that between 1984 and 1988 the rates of unprotected anal intercourse declined from 69% to 10% (for insertive partner) and from 65% to 9% (for receptive partner). However, those promising changes have not continued. Recent statistics have documented a significant increase in unprotected anal intercourse among MSM, and an increase in HIV infections has followed. In addition, the positive changes demonstrated in the White gay community have not occurred in the API gay community.(13)

During most of the epidemic, API have been notably lacking as participants in most of the studies investigating HIV risk behavior among MSM. Furthermore, lessons learned from the primarily White gay community may not apply to the API gay community.(14) In addition, specifically API gay communities are also fewer in number. However, when HIV risk behavior has been examined specifically for API gay men, they have exhibited relatively increased risk.(15) In addition, many gay API men may not identify themselves at being at risk for HIV. In a sample of gay-identified API men in San Francisco, Choi et al. reported that although 25% of the men reported engaging in unprotected anal intercourse, 85% reported that they were unlikely to contract HIV, and 95% reported that they were unlikely to transmit HIV.(15) Other issues that serve to complicate prevention efforts geared toward API MSM include racial discrimination, poverty, language, and homophobia. Given the statistics specifically regarding HIV infection combined with other, more longstanding, societal problems, prevention efforts specifically targeting API MSM are all the more imperative.

Injection Drug Users

Drug use presents particular risks for HIV transmission. Indeed, injecting is a far more efficient mode of transmitting HIV than sexual intercourse.(16) The practice of sharing drug injection equipment and an increased likelihood of engaging in unprotected vaginal, oral, or anal sex with multiple sexual partners are both possible outcomes of injection drug use. Some studies have reported that during the initial period of the epidemic, needles and syringes were used up to an average of 9 times before they were discarded.(17) Drug use, especially crack cocaine use, has also been associated with high rates of reported sexual activity and risk of sexually acquired HIV infection.(18) In addition, drug use is often practiced among networks of people, which can facilitate the sharing of needles. Due to factors such as these, drug and alcohol use in general and injection drug use in particular have been major risk factors for HIV infection in the United States.(19) Currently, injection drug use accounts for approximately 25% of annual new infections.(5) This percentage has been previously reported as being between 33% and 50%.(19)

Among API, injection drug use has not been a major risk factor for HIV transmission. Through June 2000, it accounted for 5% of both new and cumulative AIDS cases for API men. For API women, injection drug use accounted for 15% of the cumulative AIDS cases and 8% of recent cases.(5) For both genders, these figures are lower than all other ethnic groups. However, national HIV reporting does not include data from several large states with significant HIV and injection drug use epidemics among API, such as New York, and, therefore, may underestimate the number of infections.

Important ethnic differences may exist among API injection drug users in the U.S. For example, a study of Asian injection drug users not in treatment in San Francisco found that Filipino IDU had participated in riskier behaviors than other API sub-groups; eg, having sex with IDU, and having sex while using drugs.(20)

Many researchers believe that the true percentage of HIV infections due to injection drug use is difficult to estimate given the illegal nature of drug use and the hesitancy of injection drug users to admit to this behavior. Thus, evidence regarding the relative efficacy of behavioral interventions targeting drug use among API is important to evaluate in order to continue to impact rates of HIV infection in this group positively and to ensure that all injection drug users have access to prevention programs.

Heterosexuals

Although heterosexual contact is the primary mode of HIV transmission around the world, in the U.S. it accounts for only approximately 33% of new infections at present. Nonetheless, it is the fasting growing route of infection.(5) Among API, a large gender difference is evident. For API men, heterosexual contact accounts for 6% of the cumulative cases of HIV infection and 4% of the cumulative cases of AIDS cases. However, for API women, heterosexual contact was identified as the primary source of infection in 47% of the cumulative cases of HIV infection and 49% of cumulative AIDS cases.(5) The proportions for API men are comparable to Whites and lower compared to African Americans and Latinos while the proportions for API women are higher than White women, African-American women and Latinas. A final note of consideration is that the HIV infection rate for API women may be greatly underestimated, as this group has the lowest HIV testing rates of any ethnicity.(4)

However, even though heterosexual contact is the source of a significant proportion of the new cases of HIV infection and is the largest mode of transmission of HIV infection for API women, there is a dearth of literature regarding baseline risk behaviors for this population. Most of the data specific to API risk behavior in the U.S. is regarding MSM. Additional information needs to be gathered regarding the HIV risk behavior of API heterosexuals that, in turn, can be used to inform the design of interventions to prevent further infections in this population.

Youth/Adolescents

The challenge of how to improve prevention programs targeted toward sexually active youth/adolescents is a very important one, as this group exhibits high levels of sexual risk behavior. A large proportion of the young adults currently infected with HIV or diagnosed with AIDS were most likely infected during their adolescence.

Psychological factors unique to this age group place adolescents at increased risk due to their lack of perceived vulnerability. Changing risk behavior inherently involves identifying oneself as being at risk, and most surveys of adolescents have found that this age group does not perceive themselves to be at risk for most negative outcomes (eg, car accidents, HIV/STD infection, pregnancy, etc).(21,22) Adolescents are also at risk through several pathways; thus, interventions need to be tailored to the specific population of youth that is being targeted (eg, MSM, heterosexually active youth, etc).

There is a paucity of literature specifically regarding API adolescents' HIV risk behavior. Grunbaum et al. reported that API adolescents were significantly less likely to have engaged in sexual intercourse than white, African-American, or Latino students.(23) However, among those API adolescents who were sexually active, their rates of engaging in risk behaviors such as using alcohol or drugs at last intercourse and/or reporting having used a condom at last intercourse were comparable to other ethnic groups.

There is also evidence that significant differences exist among adolescent API sub-populations. For example, Horan and DiClemente reported that in a sample of 11th and 12th grade students in San Francisco, levels of sexual activity differed between Chinese (13%) and Filipino (32%) students.(24)

There has been some suggestion that traditional HIV prevention literature for adolescents would not be as applicable to API youth because of its lack of emphasis on the importance of family and community, and its focus on individual behaviors.(23)

There needs to be more information regarding the HIV risk behavior of API adolescents. Once an accurate estimation of risk is made for this population, an evaluation of effective behavioral interventions aimed at API adolescents can follow to prevent further increases in HIV infection.

Risk Not Identified

A large percentage of API HIV infection and AIDS cases fall in the category of "risk not identified." Among API men, this category represented 10% of the cumulative and 26% of the new AIDS cases and, for HIV infections, 32% of the cumulative cases and 28% of the new cases. Among API women, this category represented 18% of the cumulative and 42% of the new AIDS cases and, for HIV infections, 44% of the cumulative and 47% of the new HIV infections. For API women these numbers are substantially higher than for other ethnic groups.

Considerations Influencing HIV Prevention and Surveillance for APIs

As alluded to in the above sections, several factors may have contributed to the paucity of information regarding HIV risk behavior in API. First, many states do not collect HIV/AIDS surveillance data by API ethnicity and/or do not provide these data separately. Two of the three states with the highest numbers of API in their population (California and Hawaii) do not require HIV reporting, and New York only implemented its reporting system in 1999. Thus, the data included in CDC's surveillance reports may not be an accurate representation of API HIV infection. Second, CDC reported that, compared to other racial and ethnic groups, API men and women comprise the largest proportion of HIV testing in anonymous sites, which is usually not accounted for in national surveillance reports. Finally, the diversity of the API population in terms of culture and language provides a significant barrier to prevention efforts (eg, translating materials into several languages, ensuring the cultural sensitivity of prevention messages).

In sum, API in the U.S. are at risk for HIV via all the major modes of transmission, and in Asia there are major epidemics among heterosexuals and injection drug users. Thus, it is imperative to review our current knowledge of prevention interventions for the major behavioral risk groups systematically, so that future prevention efforts can be implemented in the most effective manner, thereby preventing additional negative consequences from HIV in the API community.

Methods

Objectives

The objectives of this review were fivefold:

To locate and describe available randomized controlled trials, controlled clinical trials, and other types of controlled intervention studies evaluating the effects of behavioral prevention interventions for HIV in API in the U.S.

To summarize the effectiveness of these interventions among API and identify the best evidence for effective interventions for future research, policy, and public health practice priorities and directions

To identify gaps in rigorous research in the field

Criteria for Including Studies in This Review

Types of Studies

We included studies that evaluated the effects of behavioral, social, or policy interventions on at least one outcome measure related to HIV transmission. We included randomized controlled trials, controlled clinical trials, and studies utilizing a comparison group (including pre-test, post-test design).

Types of Participants

We included the following types of studies:

Studies with 100% API participants in their samples

Studies with less than 100% API participants in their samples with separate analyses for the API participants

Studies with at least 50% API participants in their samples with no separate analyses for the API population

Types of Interventions

We included 3 types of interventions:

Behavioral interventions: These are interventions that aim to change individual behaviors only without explicit or direct attempts to change the norms of the community or the target population as a whole.

Social interventions: These are interventions that aim to change not only individual behaviors but also social norms or peer norms. Strategies such as community mobilization, diffusion, building networks and structural and resource support are usually used to bring about changes in social norms and/or peer norms.

Policy interventions: These are interventions that aim to change individuals' behavior, peer or social norms or structures through administrative or legal decisions. Examples include needle exchange programs, condom availability in public settings and mandated HIV education in all schools in a district.

We conducted systematic, comprehensive searches of electronic databases through hand searching key journals, by scanning reference lists of reports of relevant outcome evaluation studies and reviews and by directly contacting researchers/research organizations. The aim was to identify published and unpublished reports of U.S.-based studies that evaluated HIV/AIDS behavioral prevention interventions with study populations that included ethnic minorities (African American, Latino, API, and American Indian/Alaskan Native). (This report incorporates only studies for API, reports of other ethnic minority populations have been previously submitted.) For studies up to 1996, we searched the Behavioral Prevention Register of the Cochrane Collaborative Review Group on HIV infection and AIDS.(25) We identified more recent studies (1996 - 2000) from searches on AIDSLINE, the Cochrane Controlled Trials Register, EMBASE, MEDLINE, PsycINFO and Sociofile. For each of these databases, we developed sensitive search strategies consisting of both controlled vocabulary terms (where available) and free text terms (see Table
1 for full search strategies).

We subsequently entered or downloaded all search results into an electronic register (using BiblioScape, CG Information, Duluth, Georgia). We scanned the titles and abstracts where available and classified them according to their relevance to the review (relevant, not relevant, unclear) and for those citations deemed to be relevant also according to the study population (minority population, other population, unclear) and the type of study (outcome evaluation, other study, unclear) (see Table
2 for definitions).

In addition, we contacted researchers whom we knew to have conducted relevant research. We identified these researchers by their having published studies that had been identified as meeting the inclusion criteria (eg, HIV prevention intervention research with minority participants). We identified additional investigators through agency Web sites as having, or having had, grants funded in the area of HIV prevention intervention research. Overall, we contacted 45 researchers; 17 (38%) responded with information regarding current research and/or manuscripts (both published and unpublished).

We obtained full reports for all relevant outcome evaluation studies deemed to be relevant. We reassessed these reports for confirmation of their relevance to the review, and we coded them using a standardized coding strategy (see Table
3 and Table
4 for full coding strategy). The aim was to describe the key characteristics of each of the relevant studies in terms of the city or cities where the study was conducted, the type of intervention, the target population, ages of the study population, the sex of the study population, the percent racial/ethnic make-up of participants, the intervention setting, the intervention components, the research design, and the outcome types.

Methods of the Review

We reviewed studies for relevance based on types of participants, interventions, outcome measures, and study design.

Two independent reviewers abstracted appropriate information using a standardized data abstraction form. Information retrieved from the studies included details of the interventions and other study characteristics. Any disagreements were resolved between the two reviewers, and when necessary, by a third party.

We stratified studies according to percentage of API population, study design, targeted risk group of intervention and quality in order to better evaluate and summarize outcome information. Table
5 includes all studies with randomized controlled design with 100% API participants. Each of these studies are discussed in the text below with the highest quality studies listed first and studies of lesser quality ratings in descending order. We identified only one study with at least 50% API participants in the sample and no separate analyses.(26) This study is not discussed in the text or in tables.

Methodological Quality of Included Studies

We assessed quality of the studies in several ways that took into account our inclusion criteria and methods used in previous systematic reviews. We focused on 4 criteria, which we deemed most appropriate for the types of studies included in this review: randomization, attrition, protection against contamination, and the training/make up of the facilitators of the intervention.(27) We assessed these criteria in the following ways:

We assessed randomization according to the standards of the Cochrane Collaboration.(27) If the method of randomization were clearly described (eg, the use of random number tables or coin flips), the study was given full credit for this category (2 points). If the study merely mentioned the word "random" but did not give an adequate description, it received partial credit for this category (1 point). If the authors did not give any description or described using such allocation methods as a day of the week or dates of birth, the study did got no credit for randomization.

If attrition were less than 20% of the subjects randomized, we gave the study full credit for this category (1 point). If more than 20% attrition occurred or if the information regarding attrition were unclear, the study did not receive credit.

If proper methods were utilized to protect against any contamination of the intervention (the possibility that participants in different groups could have significant contact with each other, thereby adversely effecting the integrity of the intervention), the study received full credit for this category (1 point). If proper methods were not taken or if the methods taken were unclear, the study did not receive full credit. If the study design did not warrant a need to protect against contamination, this criterion was not used, and the study could receive a maximum of four points.

If the study included information regarding the training or makeup of the facilitators, we credited the study for this category (1 point). If this description were not included, credit was not given. (If the study did not utilize facilitators this criterion was not applicable.)

We deemed studies that received 66%-100% of points possible "good" studies, studies that received 33%-65% of points possible were "fair", and studies that received less than 33% of possible points scored were rated as having significant methodological limitations. This method of assessing quality by number of limitations has been used by the Center for Disease Control and Prevention's Task Force on Community Preventive Services.(28)

A recent paper described the HIV/AIDS Prevention Program Archive (HAPPA), which details a number of HIV prevention interventions that met stringent criteria (including scientific rigor of evaluation, quality of program implementation and positive impact on HIV risk behavior) and had been demonstrated to be effective by a panel of scientific experts.(29) The interventions listed in HAPPA focused on adult populations. We identify those studies in this review that are included in HAPPA, as well. We excluded research programs from HAPPA primarily due to containing an insufficient percentage of API participants.

Results

Search Results and Description of Studies

Overall, 271 potentially relevant studies of all ethnic minorities were identified through our searches. Descriptions of source of the studies by database can be found in Table
6. The ethnic and racial breakdown of the study population of the potentially relevant studies can be found in Table
7.

Although 39 studies were potentially relevant for inclusion in this review, we excluded most once we reviewed the full report because the sample was comprised of less than 80% API participants with no separate analyses conducted on the effects of the intervention or because there was inadequate study design and lack of methodological rigor. Therefore, we report in detail on only 2 studies that met our inclusion criteria and that are listed in Table
5.

Description of Studies Including Asian-American and Pacific Islander Participants

'Good' Studies

Studies with 100% Asian-American and/or Pacific Islander Participants

Men Who Have Sex with Men (MSM)

MSM have been the group most affected by HIV in the API community. Choi and colleagues conducted a randomized controlled trial with 329 API MSM in San Francisco investigating the effects of brief group counseling on the participants' HIV risk behavior.(13) The participants were recruited from gay API organizations, bars catering to the gay API community, and street fairs. The sample was comprised of several ethnic groups: 37% Chinese, 34% Filipino, 10% Japanese, 8% Vietnamese, and 11% other.

The intervention was conducted in small groups, and lasted approximately 3 hours. The intervention was theoretically based on the health belief model,(30) the theory of reasoned action,(31) and general social cognitive theory.(32) It was culturally sensitive in that it aimed to facilitate positive self-identity in the participants as gay API men and to improve support regarding the participants' self-image. The intervention provided information regarding safer sex, as well as techniques to eroticize and negotiate safer sex. The participants not randomized to the intervention comprised a wait-list control group.

At 3-month follow-up, the intervention group had significantly fewer partners than the control group (p= 0.0004). Although there was no significant group difference in unprotected anal intercourse some ethnic differences were found. Due to similar profiles of baseline risk status the investigators combined the Chinese and Filipino subjects. When this group was compared to the other participants, the Chinese and Filipino participants in the intervention group were significantly less likely to engage in unprotected anal intercourse at follow-up (OR, .41; p= 0.024). The remaining participants demonstrated a non-significant increase in unprotected anal intercourse at follow-up (OR, 2.35; p= 0.13). In addition, intervention participants significantly increased their knowledge (p= 0.043) and reported more anxiety about becoming infected with HIV (p= 0.039) than the control participants. The intervention did not effect significant changes in perceived HIV risk or sexual negotiation for safer sex with new or primary partners.

The authors posit that the intervention had more of a positive effect on Chinese and Filipino participants than members of other ethnic groups because these two groups comprise the majority of the API population in San Francisco. This could have meant that the other participants, being fewer in number by ethnic group, might not have been able to benefit from the social benefits of the brief group intervention as quickly or easily. For instance, they may have not received sufficient group support for safer sex.

The brief nature of the intervention may have contributed to the lack of findings regarding safer sex negotiation. This type of behavior may require interventions of longer duration in order to effect significant change. Interventions with multiple sessions have significantly and positively influenced safer sex negotiation in other samples (eg, Kalichman et al., 1996).(33)

Overall this was a well-designed and executed trial. It reported on positive findings regarding the effects of a relatively brief intervention for API gay men. Given the paucity of interventions with this population additional research is urgently needed. Future research should investigate possible ethnic differences in API sub-groups, as well as provide additional attention to negotiation skills for safer sex.

'Poor' Studies

Studies with 100% Asian-American and/or Pacific Islander Participants

Heterosexuals

Flaskerud and colleagues conducted an AIDS education program with 369 Vietnamese attendees of a Women, Infants and Children (WIC) program in Los Angeles, California.(34) The study used a nonequivalent control group design, thus, the participants were not randomized to groups. Both the intervention and control group participants were recruited from WIC programs. The intervention was designed to focus on women, although a small number of men (n=74) did participate.

The intervention consisted of a 12-minute Vietnamese-language taped educational program. A Vietnamese nurse educator was present to answer any questions following the presentation. Participants also received brochures detailing community resources for AIDS services and information. The intervention was designed specifically for the Vietnamese community. Participants completed a post-test questionnaire immediately following the presentation.

There were no significant post-test group differences in knowledge, attitudes, or practices. However, significant pre-test/post-test differences were present in the intervention group on all of these dimensions (knowledge, p <0.001; attitudes, p <0.001; practices, p <0.001). The practices sub-scale measured intentions to engage in particular behaviors such as using condom, injecting drugs and/or having multiple sexual partners.

Limitations of this study include the lack of random assignment, the lack of any follow-up, and an absence of behavioral measures. As this study was also conducted quite early in the epidemic (1988), the results might not be generalizable to current at-risk populations.

Discussion

Certain groups of API are at increased risk for HIV infection. We have reviewed two studies of different quality and methodological strength that reported on interventions specifically addressing these risk groups among API. We identified 1 study that focused on MSM and 1 study that focused on heterosexuals.

Of the 2 studies described, 1 found some significant levels of behavior change following interventions aimed at decreasing HIV risk behavior. Unprotected anal intercourse was the primary behavioral outcome used to examine risk, along with number of partners.

Although some positive effects were reported, the often very brief follow-up periods limit the strength of these findings. Thus, it is impossible to discern the lasting impact of interventions for studies that reported positive behavior change but had short follow-ups (eg, 3 months).

Components of Effective Interventions

Certain components were present in the interventions that achieved positive behavioral changes. These included cultural sensitivity and skills training. Specific comments regarding these components were reported in the individual descriptions of the studies. However, general statements can be made regarding these components:

The interventions were designed in order to reflect specific needs and/or characteristics of the API community. For example, the interventions incorporated aspects of culture into the intervention and had API facilitators. However, there needs to be attention paid in the future to testing these components against less culturally relevant interventions in order to understand better the impact of this feature. In addition, important differences between sub-groups of API populations need to be investigated (eg, risk within the Chinese vs. the Filipino community).

Interventions that incorporated skills training achieved positive results. When skills training was compared to purely informational interventions, the skills-training participants reported more positive changes in their risk behavior. However, some skills (eg, safer sex negotiation) may need interventions of longer duration in order to effect positive change.

Gaps in Research

We identified several gaps in the research. Of deepest concern is the extreme paucity of well-designed intervention studies fitting our inclusion criteria that were specifically targeted to API populations. We identified only 2 interventions consisting of 100% API participants, no studies with at least 80% API participants and no studies with separate analyses for API participants. Given the rates of new infection for API, this lack of studies is cause for concern.

In addition, we found only one study focusing on either API MSM or gay men. As this is the group within the API community most at risk for HIV infection, intervention trials that specifically focus on this population should be an immediate research priority. While some large-scale studies focusing on HIV prevention in MSM have recently gotten underway (eg, a national multi-site study funded by CDC), additional attention needs to be specifically geared towards this population.

As we were unable to identify any studies that focused on adolescents, additional attention should be given to this group. In addition, within adolescents, there are several sub-populations that warrant attention. For example, younger adolescents may receive many benefits from interventions that could have a substantial impact on behavior as patterns and habits are being formed. Interventions that occur later in adolescence could have less of an impact after risky behaviors have already become a habit (eg, Millstein et al., 1993).(35) In addition, gay-identified API youth will likely be an important group to study.

Additional studies are also needed that focus on API heterosexual women. This group appears to be at increased risk,(5) but the only study we identified was from 1988. It also appears that basic surveillance regarding this populations is needed-perhaps exacerbated by the low level of HIV testing among API women.(4)

Final gaps in research that we would recommend addressing are methodological in nature. First, future studies should allow sufficient time for follow-up. Although many of these interventions are conducted with hard-to-reach and, thus, hard-to-follow populations, longer periods of follow-up are necessary in order to determine whether or not effective behavior change has occurred.(36) Intervention studies that include follow-up periods of a minimum of 6 months should be the rule. Second, studies that include some percentage of API participants (or indeed a significant proportion of any racial and ethnic group) should report separate analyses for those participants. For example, if an intervention were conducted with both API and White participants but these participants were not separated in the analysis, it is frequently difficult to ascertain the relative success of the intervention in each group. Finally, studies should attempt to include a biological outcome (eg, STD reinfection) where feasible.

Ongoing Studies

We have identified a few ongoing studies that are conducting interventions to reduce HIV risk behavior in API. This summary is preliminary and will be updated as we continue to identify ongoing studies.

We are aware that the Office of AIDS Research, the National Institute of Mental Health, the National Institute on Drug Abuse, CDC, and other governmental agencies have made research investigating HIV risk reduction among communities of color a priority. One such study is the CITY trial, funded by the CDC. It is a community-level trial of an intervention aimed toward preventing sexual transmission of HIV among young MSM. It has a catchment area focusing on API MSM in Seattle. It is anticipated that the number of research reports describing interventions in API populations will continue to increase as the results of these intervention studies become available. In addition, many community-based organizations have conducted interventions with API populations (particularly MSM) focusing on preventing HIV. However, these have typically not included comparison or control groups, and results are often not published in the scientific literature.

Conclusions and Recommendations

In sum, we have identified and reviewed 2 intervention trials of different methodological quality aimed at reducing the risk of HIV infection for API in the U.S. We conducted a rigorous search of the literature and contacted leading researchers in the field in order to ensure the comprehensiveness of this review. We organized the review by the 4 major risk groups for HIV infection (MSM, IDU, heterosexuals, and youth/adolescents). We reviewed evidence for interventions in which API comprised 100% of the participants or in which there were separate analyses for API participants. We also ranked studies by using standardized quality ratings.

We found some consistencies between the 2 studies that produced positive results. These interventions were culturally sensitive to the needs of API and provided the participants with skills training. Examples of positive outcomes were decreasing the number of sexual partners, decreasing the frequency of unprotected anal intercourse and improving HIV knowledge. All of these outcomes are associated with decreased risk of HIV infection. We also identified one striking gap in the literature- - only one completed intervention study specifically targeting API gay men and/or MSM, the group most at risk for HIV infection in the API population. Implementing additional intervention studies in this group is an urgent priority.

Our recommendations are as follows:

Additional studies on API are an urgent research priority, with emphasis on API MSM and gay men and on heterosexuals. Studies should have sufficiently large sample sizes to identify subtle effects and inter-ethnic group differences and a sufficiently long follow-up period to discern long-term effects.

Interventions should be culturally sensitive and take into account cultural differences between sub-groups of API (eg, Chinese vs. Filipino).

Interventions should include skills-training components. This includes practical skills training such as the correct use of a condom but also encompasses techniques such as improving communication and decision-making skills regarding negotiating safer sex practices and training in resisting peer pressure.

Interventions should be theory-based, and interventions that have been grounded in cognitive-behavioral theory have produced the most consistent positive results.

Our recommendations to investigators planning research interventions:

Adequate sample sizes should be obtained in order to increase the chances of discerning the effects of the intervention. Funding agencies should be prepared to make this additional investment.

Studies should attempt to measure behavior change over long periods of time (at least 6 months) in order to determine whether behavior changes were maintained over long periods of time. Funding agencies should be prepared to make this additional investment.

Studies that do not use a control group (ie, those that compare 2 interventions) should consider designs (eg, a crossover design) that will allow some comparison to a no-intervention or a standard intervention group.

As the API community includes a vast number of different cultures, studies should identify different demographic information about API participants (ie, U.S.-born or immigrants, country of origin). Studies of racially-mixed populations should also conduct separate analyses for API participants, including separate analyses by demographics as well as the effects of the intervention on API participants.

As we enter the third decade of the AIDS epidemic, API are increasingly at risk for HIV infection. However, this review demonstrates that effective approaches and techniques exist that are successful in reducing the HIV risk behavior of the highest risk groups in the API population. The scaling up and implementation of interventions that we know to be successful should be a priority. Additionally, funding, designing, and implementing interventions specifically targeting API gay men and MSM should be an immediate priority for policy makers and researchers.

References

1.

United States Bureau of the Census. Resident Population of the United States. http://www.census.gov.

2.

United States Department of Commerce, Economics and Statistics Administration, Bureau of the Census, We the American...Asians, September, 1993.

Coates TJ, Faigle M, Koijane J, Stall RD. Does HIV prevention work for men who have sex with men (MSM)? A report prepared for the Office of Technology Assessment, for the Congress of the United States. August, 1995.

Marin BV. Analysis of AIDS prevention among African Americans and Latinos in the United States. A report prepared for the Office of Technology Assessment, for the Congress of the United States. August, 1995.